Assessing Monkeypox (MPX) Vaccine Eligibility Across the United States

Background

The current monkeypox (MPX) outbreak continues in the U.S., with more than 22,000 cases having been confirmed in less than five months, and likely many more yet to be diagnosed. While cases seem to be declining somewhat, they continue at a high level. The World Health Organization (WHO) declared the current outbreak to be a Public Health Emergency of International Concern on July 23, 2022 and the U.S. Department of Health and Human Services (HHS) declared MPX to be a national public health emergency on August 4, 2022. Vaccines are a key component of the public health response to the outbreak. The federal government announced plans to begin providing MPX vaccines to state and local jurisdictions from the Strategic National Stockpile (SNS) in June and has been ramping up supply and distribution since, primarily focusing on JYNNEOS, the preferred vaccine due to its safer profile compared with the other available vaccine (ACAM2000). JYNNEOS is being allocated to jurisdictions “to meet the needs of at-risk individuals and [HHS has] prioritize[d] the hardest-hit jurisdictions, which have high case burden and transmission rates for monkeypox” and the largest at-risk communities. Most of those affected and at risk to date are gay and bisexual men and other men who have sex with men (MSM).

While supply has increased over time, supply challenges hampered the initial roll out and continue in some areas of the country. Given who is at most risk and supply limitations, Centers for Disease Control and Prevention (CDC) guidance to jurisdictions for determining MPX vaccine eligibility currently focuses on the following priorities (also see Table 1): post-exposure prophylaxis, or PEP (vaccination after a known exposure) as well as expanded post-exposure prophylaxis and PEP++ (vaccination for those with actual or presumed exposure due to their risk factors or recent experiences). A third strategy, pre-exposure prophylaxis, or PrEP, for specific groups who might be at risk due to occupational exposure (e.g., laboratory workers) is also identified, though not prioritized at this time.  Still, each jurisdiction determines its own distribution approach, including its eligibility criteria, and which groups are prioritized for vaccination.

We sought to assess vaccine eligibility criteria across the country, focusing on state and local jurisdictions that receive direct vaccine allocations from the federal government, including all 50 states, Washington, D.C. and five cities (Chicago, Houston, Los Angeles, New York City, and Philadelphia). We compared local eligibility criteria to the approach recommended by CDC, and identified which groups and/or situations are being prioritized for vaccination. We also assessed the extent to which information on vaccine eligibility was clearly available. Our analysis is a point in time assessment, with data as of September 12, 2022, and as such it is possible that criteria may have changed. Links to source documents are included.

Overall, we find that almost all jurisdictions have adopted PEP and PEP++ vaccination strategies, with a much smaller number employing PrEP as currently defined by CDC.  However, there is substantial variation in how eligibility is defined within, and in some cases beyond, these categories. Additionally, several jurisdictions lack clear criteria or information about who is eligible or where to get vaccinated. Such variation has implications for access and may affect how equitable roll-out of vaccination is across the country, particularly as new MPX cases are increasingly concentrated among MSM of color.

Findings

As of September 12, across the 56 jurisdictions assessed, we find that:

•  Almost all jurisdictions assessed (52 of 56) indicate that they are offering PEP (vaccination for those with known contacts). Among the four remaining jurisdictions, two (Illinois and New Mexico) do not provide detail regarding eligibility criteria in any category. The other two (D.C. and South Carolina) do not clearly state whether they are offering vaccination to those with known contacts but both offer vaccination to those with suspected or likely contacts (and actually go beyond the CDC approach in some ways); while this implies that known contacts are eligible for vaccination, the criteria are not clear on this point.
• Similarly, almost all jurisdictions (51 of 56) offer PEP++ (vaccination not just after exposure, but also after presumed exposure due to risk factors or recent experiences).
  • This includes 37 that specifically identify gay, bisexual, and other MSM, and in some cases also include transgender and non-binary individuals, as recommended by CDC.
  • In some cases, individuals in these groups are also required to meet additional criteria following the approach laid out by the CDC, such as limiting eligibility for MSM to those who use dating apps, have had more than one sex partner in the last 14 days and/or have visited sexual venues (saunas, sex parties, bathhouses, etc.), or are HIV PrEP users.
• A smaller number of jurisdictions (18) indicate that they are offering MPX PrEP for health care workers who may be exposed due to occupational risk. These individuals were typically laboratory workers performing MPX testing or clinicians collecting MPX specimens, but sometimes a broader approach was taken.
• There are also many jurisdictions (24 of 56) that go beyond the CDC-defined categories to provide broader eligibility for vaccination in stand-alone categories as follows:
  • Seven offer vaccination to anyone considered to be at increased or general risk (not defined further).
  • Nineteen offer vaccinations to anyone at increased sexual risk specifically (e.g., not limited to men who have sex with men, transgender or gender non-conforming individuals).
  • Sixteen offer vaccination to anyone engaged in sex work (and in some cases, to those working in commercial sex venues).
  • Nine offer vaccination to anyone who has HIV, most of which also include someone who has had a recent STI. An additional 15 prioritize vaccination or emphasize the importance of vaccination among people with HIV but do not include people living with HIV as a clear eligibility group.
  • Eleven offer vaccination to anyone using HIV PrEP.
  • Others offer vaccination to additional groups of individuals considered to be at increased risk such as intravenous drug users (1); those in local jails or people who have been recently incarcerated (2); and those experiencing homelessness (3 as an eligible population and 1 as a prioritized population).
• Additionally, several jurisdictions allow for more local or provider-specific eligibility determinations. Eight specify that eligibility may be determined on a case-by-case basis, even when, in some cases, other eligibility groups are defined, and eight devolve all or some eligibility decision-making to local health departments or authorities.
• In terms of signing up for a vaccination appointment or identifying where vaccination is being offered, we found mixed results. Many jurisdictions provide links for sign-ups, though some are for “pre-registration” only. Several instruct individuals to reach out to their local health departments or provider. In some of these cases, local health department contact information is provided, or a list of community-based vaccine sites and contact information. Other jurisdictions provide a health department phone number to call for additional information, eligibility screening, or for making an appointment. Jurisdictions often provide more than one of these options. However, in other cases, information on how to sign-up is less clear. For example, it is somewhat common for individuals to be instructed to reach out to their local health departments for vaccination but no further contact information is provided.
• There is also variable information provided about residency requirements. While most (43 of 56) provide no clear information about residency requirements at all, 10 specify that vaccination is limited to those who live, work, go to school, or receive health care in the jurisdiction. A few state that exceptions to this limitation are possible and three explicitly state there is no residency requirement.
• Finally, in many jurisdictions, eligibility information, even if ultimately available, was hard to find or unclear. This included jurisdictions where different aspects of eligibility criteria were presented in multiple places, including, sometimes, in health care provider instructions (vs. consumer-facing materials); stand-alone press releases; and/or in online registration forms that required multiple click-throughs. In other cases, certain eligibility information was only available in health care provider materials. Several instances of contradictory information were found– information in PDFs might have different eligibility criteria than what was posted to the website, for example. Eligibility information was especially challenging to ascertain in four jurisdictions (Illinois, Indiana, Maryland and New Mexico). Finally, some jurisdictions indicated they were following CDC’s eligibility guidance but then provided much more limited or more expansive eligibility criteria.

Discussion

Jurisdictions have approached defining populations eligible for MPX vaccine with substantial variation and these decisions could have an impact on curbing local transmission. In some cases, the information on vaccine eligibility or access process is hard to locate or not very clear, potentially creating barriers, limiting individuals’ ability to understand whether they are eligible and/or how to find vaccination. Variation also means that a higher risk individual in one jurisdiction will have access to vaccination whereas someone with similar risk in different region would not. Many jurisdictions note that the eligibility requirements are in place due to limited vaccine supply, and several suggest that they will broaden eligibility in the future when more vaccine is available. Until that point, an understanding of how local vaccine eligibility is defined and how clear the vaccination process is for those at risk may offer insights into take-up and equity moving forward.